Tip: Query for Noncompliance with medical treatment (V15.81)
Editor’s note: This blog was written by Brian Murphy, CPC, the director of the Association for Clinical Documentation Improvement Specialists, for the ACDIS Blog. Read the original post here.
CDI specialists should be on the lookout for indications of patient noncompliance with medical treatment when reviewing patients’ charts, says Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services with 3M Health Information Systems (HIS) and a member of the ACDIS advisory board.
According to Garrison, payers are increasingly denying hospital readmissions and the problem is likely to worsen with the nationwide rollout of the Recovery Audit Contractor (RAC) program and CMS’ increasing scrutiny of the cost of readmissions. “Readmissions can be the result of, or influenced by, patients who leave the hospital and refuse or elect not to follow recommended treatment plans (by choice, by misunderstanding of discharge instructions, or due to costs), which may cause their condition to worsen, resulting in a readmission,” Garrison says.
However, CDI specialists can assist facilities by identifying when noncompliance plays a role in the readmission. By securing the necessary documentation to allow coders to report V15.81, hospitals can use this documentation and coded data to help prevent or appeal denials, Garrison says. “If the V code is reported in the top nine diagnosis codes when it is transmitted on the UB-04, (it allows) the payer to have the knowledge that patient noncompliance may have contributed to the readmission,” she says.
“I have always recommend the use of the V15.81 code for noncompliance to both coders and physicians when supported by the clinical documentation,” adds Gloryanne Bryant, RHIA, CCS, CCDS, regional managing HIM director, NCAL Revenue Cycle of Kaiser Foundation Health Plan Inc. and Hospitals in Oakland, CA, and a member of the ACDIS advisory board. “I agree this is helpful, but mostly for understanding which patients really are not following medical instructions. Is it the diabetic patient or the dialysis patient, etc?
“It further explains and provides insight into healthcare resource use, length of stay, costs, and readmission rates,” Bryant adds. ”I would recommend that facilities run a data report on their inpatients with this V code assigned and conduct some audits and reviews to gather insight. I would also track/trend this V code over time and share the information with providers.”
About the Author: Julie works in the case management market at HCPro, Inc. She works on all of HCPro’s product lines for case managers including books, audio conferences, journals, videos and an eNewsletter. To contact her with questions, comments, or to be a blog writer, email jmcginley@hcpro.com.
Colleen DeMarco | Jul 29, 2009 | Reply
IT HAS BEEN MY PERSONAL EXPERIENCE THAT LABELING PATIENTS AS NONCOMPLIANT IS MOST OFTEN A JUDGEMENTAL ACTION—PATIENT USUALLY LACKS RESOURCES (SUCH AS TRANSPORTATION, AVAILABLE AND ABLEBODIED CAREGIVER, MONEY, OR KNOWLEDGE/UNDERSTANDING, ETC) THE REAL CASEMANAGEMENT OCCURS WHEN THE NEED IS IDENTIFIED AND RESOLVED. IT IS NOT ONLY SUPERFICIAL AND MEANSPIRITED TO CALL A PATIENT NONCOMPLIANT-IT IS DEROGATORY AND UNPROFESSIONAL.
Stephanie | Jul 29, 2009 | Reply
Many times it has been our experience patients truly are non-compliant no matter how much education is provided or what support services are arranged as they continue the same unhealthy behavior patterns (unhealthy diets, tobacco usage, sedentary lifestyle, hit and miss taking medications, not keeping follow up appointments with medical providers, failure to complete oral antibiotic therapy as prescribed, family unwillingness to participate in care of loved one, etc.) all of which are under the patient’s control and frequently land them back in the hospital. It seems unreasonable to hold medical providers/entities responsible for those choices or to make medical providers/entities fiscally liable, although that seems to be the direction we’re going. Our hospital Case Management staff does a wonderful job identifying, discussing and arranging resolutions for patient’s post discharge and home needs; unfortunately, the Case Managers can’t go home with patients to make sure they comply! Patients need to take their medical conditions more seriously and do their part to stay healthy as recommended by their physician(s). If insurances did not cover treatment and held the patient responsible when they are identified as non-compliant, behaviors might change and people would get healthier thus saving millions of healthcare dollars.
Lamona Rankin | Jul 30, 2009 | Reply
Sometimes the issue with readmissions is that the patient is dealing with end of life issues in a culture that is not supportive of the overwhelming needs for patients with chronic diseases. We have so many options/treatment choices today to provide for patients. Many times patient/family members want everything done for these patients despite discussion of accepting the inevitable. As a nurse and having had cancer,it is very difficult to decide when to give up trying to aggressively fight a chronic disease.
We as a society need to be comfortable discussing this outside the healthcare arena. As we develop more treatment options this issue of cost will become more pronounced.
The old data years ago showed that the highest costs to the Medicare system was in the last year of the patient’s life.
(Is this still true??) Are readmissions increased and considered avoidable during this time?
What I have read about the countries with lower cost in healthcare is more family involvment and a better support system, more interest in healthy life style, less stressful lives or the ability to handle stress better and a less complicated medical management approach. However, as a result, the availability of high tech and cutting edge medical care is not as prominent as we see here. It takes much longer to accomplish more basic treatment.
I would like to hear from people exposed to healthcare systems in other countries? especially whether their culture/family is supportive during chronic illness and end of life needs. Is it a more simplistic approach?
Which would you choose for yourself? Simplistic approach vs cutting edge medicine? Are readmissions an issue?
Thanks